Garry Rayno's State House Dome: More debate over ACA exchanges

In less than a month, people will be able to begin using Affordable Care Act-created exchanges to enroll in health insurance plans, but little information had been available about what those plans will entail - until last week.

Some of the information was presented before a health care reform oversight committee, and it caused a partisan fire storm, with charges and countercharges and more charges.

The conflagration's catalyst was Anthem Blue Cross Blue Shield's decision to limit the number of hospitals in its provider network for the plans it will offer on the exchange.

Anthem is the only health insurer to offer health plans on the state exchange, although Delta Dental has been approved for dental insurance.

Anthem's limited network will disrupt health care for some of the people using the exchange if their local hospital and doctors are not in the network, but not for most people who have health insurance through their employers or through government programs such as Medicare and Medicaid.

Anthem's Pathway plan was submitted to the Insurance Department for review and recommended to the Center for Medicaid Services, which ultimately has to approve it before Anthem can offer its plans on the exchange.

Republicans wanted to know why state regulators approved such a limited plan, which they charged would "ration health care," and they blasted Gov. Maggie Hassan and her administration for sitting on the information.

Democrats turned the finger-pointing back to Republicans, saying they have tried to sabotage the ACA since it passed Congress and were the ones who prohibited the state from running its own exchange with the authority that would go with it.

Democrats and Insurance Department officials said state law forbids releasing plan and rate details because they are considered proprietary information until a plan goes into effect and that has traditionally been the way the department has operated in the past.

Said Deputy Insurance Commissioner Alex Feldvebel: "The Insurance Department considers plan filings 'confidential, commercial or financial information' under RSA 91-A: 5 IV until they are approved and effective or made public by the carrier itself. In this instance, Anthem's filing has not yet been approved. The department has conditionally approved the filing and provided it to CMS (Center for Medicaid Services) for their review."

The section of law cited by Feldvebel exempts from the Right-to-Know Law "records pertaining to internal personnel practices; confidential, commercial, or financial information; test questions, scoring keys...."

But the statute also says: "Without otherwise compromising the confidentiality of the files, nothing in this paragraph shall prohibit a public body or agency from releasing information relative to health or safety from investigative files on a limited basis to persons whose health or safety may be affected," which would appear to indicate the information could be released to people affected by the plan.

The other contentious issue is House Bill 1297, passed in 2012 by the Republican-dominated Legislature, which forbids the state to operate its own exchange and restricts state agency participation in setting up the exchange.

Hassan's communication's director, Marc Goldberg, and Democrats charged the law has tied the hands of insurance regulators because they do not have the ultimate authority to approve plans.

The law says: "No New Hampshire state agency, department, or political subdivision shall plan, create, participate in or enable a state-based exchange for health insurance under the act, or contract with any private entity to do so," but also says, "State agencies or departments may interact with the federal government with respect to the creation of a federally facilitated exchange for New Hampshire."

At the time the bill was before lawmakers, state agencies argued they needed to be able to retain their traditional authority to manage and review insurance plans and to determine eligibility for social service programs even if the state could not run its own exchange.

Bill supporters said at the time the proposed legislation would allow the departments to maintain their traditional roles.

The law itself allows the commissioner to maintain their traditional authority "to the extent allowed under (the ACA)."

Republicans asked how state regulators could have approved Anthem's plan when it would result in patients having to change hospitals and doctors and traveling greater distances for care.

The Insurance Department said under state law it has the independent authority to review plans to determine whether they meet state and federal standards, including plan details, rates and network adequacy.

Because New Hampshire partners with the federal government in the exchange, the arrangement is slightly different with federal regulators.

The state reviews plans for both state and federal standards and makes a recommendation to the CMS, but the federal agency makes the final determination as to whether the plans meet federal and ACA requirements, the department said.

That should be confusing enough that both sides should be able to continue their talking points for some time.

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Which Is Better? Expanding Medicaid eligibility can be seen in a new light after Anthem revealed last week its Pathway network includes only 16 of the state's 26 hospitals.

A person using the state's federally run health insurance exchange could have some very difficult choices to make if the state does decide to expand eligibility to all adults at or below 138 percent of the federal poverty level.

One of the options being discussed is requiring adults between 100 percent and 138 percent of the poverty level to use the exchange to choose a private insurance plan while Medicaid would pick up much of the bill.

The private plans through the exchange have varying deductibles and co-pays, depending on how much a person pays for coverage.

If the state decides to use the private insurance carriers for those between 100 and 138 percent, it would have to pick up the cost for the co-pays, deductibles and whatever else the private insurance doesn't cover that Medicaid does.

And Medicaid has requirements about how far patients have to travel for care. Conceivably, a person on Medicaid would have to travel less distance to receive care and would have travel expenses reimbursed.

The state's Medicaid program will have managed care by the time the individual and small-business policies begin coverage, Jan. 1. We don't know the Pathway network plan details, so we do not know whether it will be managed care or a pay-for-service program.

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ROADS AND BRIDGES: The two-year state operating and capital budgets are in place, so it must be time for the biennial update of the state's 10-year transportation improvement plan.

The Governor's Advisory Commission on Intermodal Transportation began holding a series of 25 meetings across the state last week to gather input from the public, elected officials and local government staff.

The plan is limited by federal, state and local money sources and has been scaled back substantially in the past few years as federal highway funds have decreased and the state highway fund has failed to keep up with inflation or benefit from more fuel-efficient vehicles.

The state's nine regional planning commissions develop their regional priorities and send them to the Department of Transportation, which does a quick edit and sends them to the GACIT, which is composed of the five executive councilors and the Department of Transportation commissioner.

That group's recommendations are sent to the governor, who decides what projects to support and then sends the revised plan to lawmakers.

The House and Senate make their recommendations by the end of June.

There is certainly ample room for political input and perhaps pressure along the way, particularly in light of the money limitations.

Much of the plan is focused on projects in the federal highway system, such as the widening of Interstate 93 from Salem to Manchester. There is about $145 million to $155 million a year allocated in federal highway funds to the state.

Currently, the project has enough money to continue work through the fall of 2015, but beyond that, the money dries up.

That is why some lawmakers are working to come up with a smaller gas tax increase that might be able to pass the House and Senate next year.

The Senate killed the House-passed 12 cent increase in the gas tax this year because senators had another solution.

Senate Bill 152 would have allowed one casino in the state and allocated a little less than half of the money generated by gambling for roads and bridges. The bill was killed by the House.

The argument over how to pay for roads and bridges is not likely to diminish next session, particularly with gambling proponent and SB 152 sponsor Chuck Morse holding the gavel as Senate president.

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Purple Heart Plates: After four years of trying, Sen. Lou D'Allesandro of Manchester persuaded his fellow lawmakers to allow the widows of Purple Heart license-plate holders to retain their husband's or wife's plates until they die or no longer register an automobile.

D'Allesandro and Sen. David Boutin of Hooksett helped Leo Brown, New England regional coordinator of the Order of Purple Heart, transfer the first Purple Heart license plate since the law passed this session.

The three transferred the plates of Jeanne LeVasseur's husband to her automobile Friday. LeVasseur lives in Hooksett.

"The Fiscal Committee bypassed the budget process to spend $93 million without a single word of public input," said Rep. Josh Moore, R-Merrimack.

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